ABC UNIVERSITY NEW STUDENT-ATHLETE INFORMATION FORM 201_-1_ ACADEMIC YEAR

Transcription

1 ABC UNIVERSITY NEW STUDENT-ATHLETE INFORMATION FORM 201_-1_ ACADEMIC YEAR Name: _ Sport: Student ID/Social Sec Number: Date of birth: Gender: International student: (circle one) YES NO Ethnicity: (circle one) Alaskan/American Indian Asian/Pacific Islander Black Hispanic White Nonresident Alien Other (please describe): Housing: (circle one) On campus Off campus Drivers license number: State: _ Date entered ABC University (part time or full time): Date entered any institution (part time or full time): _ Local phone: ( ) Permanent phone: ( ) Cell phone: ( ) address: Local address: Permanent address: City: State: Zip: PARENT/LEGAL GUARDIAN INFORMATION 1. Parent(s)/Legal Guardian(s) Names(s): Relationship(s): Home phone: ( ) Work phone: ( ) Other phone: ( ) Address: If different from student-athlete's permanent address 1

2 2. Parent(s)/Legal Guardian(s) Names(s): Relationship(s): Home phone: ( ) Work phone: ( ) Other phone: ( ) Address: If different from student-athlete's permanent address INSURANCE What health insurance policies is the student-athlete covered under (circle one): Personal Parents Guardian None HIGH SCHOOL/PREPATORY SCHOOL INFORMATION Name of high school Location Graduation date (m/yr) RECRUITMENT STATUS (circle answers) 1. Did a member of the athletics staff or anyone representing ABC University provide transportation for you to visit the campus? YES NO If yes, who provided the transportation? 2. Did you make an "official visit" to ABC University, at the expense of the athletics department? YES NO 3. Did anyone from the ABC University athletics department initiate or arrange a t elephone contact, on more than one occasion, with you or a member of your family for the purpose of encouraging you to attend ABC University and participate in athletics? YES NO 4. Did anyone from the athletics department at ABC University visit you in your home, at your high school or any other place for the purpose of encouraging you to attend ABC University and participate in athletics? YES NO 5. Did you sign a National Letter of Intent (NLI) or written offer of athletics aid to attend ABC University and participate in athletics? YES NO PREVIOUS COLLEGE ATTENDANCE INFORMATION Name of Institution Two-Year/Four-Year College Dates Attended FT/PT Graduate Y/N 2

3 1. Did you practice at any institution listed above? YES NO 2. Did you compete in varsity intercollegiate athletics at any institution listed above? YES NO If yes, which institutions? What semesters/quarters: (e.g., F10, S11): 3. Did you sign a National Letter of Intent (NLI) to attend any of the above institutions? YES NO 4. Did you receive athletically related financial aid at any of the above institutions? YES NO If yes, how many years did you receive athletically related aid? 5. Did you participate on any club teams while you were enrolled at any of the above listed institutions? Did the institution sponsor the same sport at the varsity level? YES NO ELIGIBILITY Since graduation from high school, have you ever competed in organized athletics competition, either as an individual or as a member of a team, that was not one of the college or university teams listed earlier? YES NO Time Lapse Statement: If you have not continuously attended college as a full-time student each semester or quarter since your graduation from high school, please describe your activities during the period you were not in school (i.e., work, military service, church mission) and the exact time period. 3

4 AMATEURISM 1. Have you ever accepted a loan, payment of expenses (e.g., travel, lodging, meals) and/or agreed orally or in writing to be represented by an agent/professional sports organization? YES NO 2. Has anyone (other than your immediate or extended family) given you cash or gifts of value since agreeing to participate in ABC University athletics program? YES NO 3. Have you ever wagered a bet on a college or professional athletics contest(s)? YES NO EMPLOYMENT INFORMATION Do you plan to work in the 201_-1_ academic year? YES NO Name of employer: City/State: Dates of employment: Job title: Job duties: Salary: How did you obtain this job? Did anyone connected with ABC University athletics help you get this job? YES NO If yes, who was it? What did they do? My employment falls in the following categories: Work-study Intern University Commercial Self CAR REGISTRATION Will you have use of a vehicle on- or off-campus this year? YES NO If yes, please fill in: Year: Make: Model: License plate number: State: Person(s) the car is registered to: Did you purchase an ABC University parking permit: (circle one) YES NO 4

5 I understand the ABC University athletics compliance office will verify this car registration information through the university police department. By initialing here I consent and give my permission for this information to be disclosed to the compliance office by the university police during this academic year, 201_-1_. Student-athlete's initials: I certify that I have not received special discounts or financing while purchasing my personal vehicle due to my association with the athletics department. Student-athlete's initials: I authorize ABC University to use my name or picture to generally promote ABC University athletics events, activities or programs. Student-athlete's signature: FINANCIAL AID Any financial aid awarded from agencies outside of ABC University and your immediate family MUST be reported to the financial aid office. Please list any such awards, the awarding agency and the amount below: I certify that my answers are complete and correct. I understand that ANY FALSE OR INCOMPLETE STATEMENTS IN THIS HISTORICAL FORM/REPORT MAY MAKE ME INELIGIBLE FOR INTERCOLLEGIATE ATHLETICS COMPETITION and/or any athletically related financial aid at ABC University. If any of the information I have supplied in this report changes during the year, I agree to notify the compliance office as soon as possible. Student-athlete's signature: DISCLAIMER: The information contained in this document is provided as a reference to member institutions and does not constitute binding advice on compliance with NCAA rules and bylaws. Any inquiries related to NCAA rules and bylaws should be directed to the NCAA academic and membership affairs staff. The most up to date information regarding NCAA Division II rules, bylaws and procedures can be found by accessing the information on LSDBi. The National Collegiate Athletic Association 5 August 24, 2011 MSJ:kas